The Technical Evolution and Procedural Outcomes of the Contemporary Hybrid Operative Procedure for Incapacitating Post-Thrombotic Iliofemoral and Inferior Vena Caval Obstruction

Abstract

Chronic, post-thrombotic iliofemoral and inferior vena cava (IVC) obstruction is associated with debilitating post-thrombotic morbidity. Whereas balloon venoplasty and stenting of the post-thrombotic iliac veins are often successful, these procedures performed in the presence of a diseased or occluded common femoral vein (CFV) are frequently associated with incomplete recanalization and failure. Open surgical CFV endovenectomy is designed to provide venous drainage from the involved limb, to restore venous inflow to a recanalized iliocaval segment, and to provide a nondiseased landing zone for the iliac vein stent, thereby improving procedural success and reducing the severity of the post-thrombotic syndrome. During the past 8 years, the procedure has evolved to one in which success can be anticipated and complications and failure minimized. Thirty-one patients undergoing CFV endovenectomy and proximal endoluminal reconstruction (iliac, IVC) have been analyzed. The initial techniques of patient management were compared with the present techniques, evaluating procedural complications and failures. The initial procedure consisted of preoperative venography, CFV endovenectomy, patch venoplasty, and intraoperative passage of a guidewire into the patent IVC followed by venoplasty and stenting, with postoperative systemic anticoagulation. Iliac vein rupture was treated with a stent graft. The contemporary procedure begins with preoperative venography with guidewire/catheter advancement into the IVC the day before the operative procedure. Patients receive preoperative combined platelet inhibition. The following day, the patient is operated on. This procedure consists of a complete CFV endovenectomy, patch venoplasty, intraoperative balloon venoplasty and stenting of the IVC (if necessary) and iliac veins, landing of the stent into the endovenectomized CFV above the saphenofemoral junction, completion intravascular ultrasound, construction of a small (4-mm) distal CFV-arteriovenous fistula, low-dose regional anticoagulation with unfractionated heparin through a popliteal vein sheath, conversion to oral anticoagulation with warfarin, early ambulation, and indefinite oral anticoagulation. Ruptured iliac veins are now treated with a second stent relining the first. Of the 17 patients, 9 (53%) treated with the early technique had major complications: 4 iliofemoral thromboses, 3 major wound bleeds, and 2 wound infections. One iliac vein rupture treated with a stent graft thrombosed. Of the 24 patients treated with the contemporary techniques, 2 (8%) had procedural complications, 1 seroma and 1 wound infection. One iliac vein rupture, treated with a second stent relining the first, remains patent. The contemporary hybrid operative procedure for incapacitating post-thrombotic iliofemoral/venacaval obstruction increases procedural success and reduces complications compared with the initial technique. The contemporary technique is preferred for all patients undergoing hybrid operative management of iliofemoral/venacaval post-thrombotic occlusion involving the CFV.